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Pre-participation Screening of Athletes
Responsibility lies on physicians to exercise prudent efforts and judgment to identify life-threatening diseases in athletes to minimize risks associated with competitive sports and to protect health of such individuals (1-4). The extent to which preparticipation screening can be supported at any level (high school, college, professional associations) is mitigated by the considerations of cost-efficiency and practical limitations. In addition, acceptance of the unlikelihood to achievement of “zero risk” and views of disclosure of cardiovascular risks associated with competitive sports to athletes as a part of the overall uncertainty of living as well as remunerations for athletic performance often present hindrances to ethical obligations to assure that athletes are not subjected to unacceptable risks. Educational institutions and professional teams in the United States are required to utilize reasonable care in their athletic programs for the purpose of detecting medically significant cardiovascular abnormalities (1). However, there is no clear legal precedent regarding the duty to conduct such screenings. In the absence of legally-binding requirements to perform cardiovascular screening and/or to diagnose cardiac disease in young competitive individuals established by state law or athletic governing bodies, most institutions and teams rely on the team physician to determine and implement appropriate procedures. However, in the event that a physician cleared an athlete with a potential (yet undiscovered) cardiovascular condition is not necessarily legally liable for an injury or death caused by the undetected disease. The failure to diagnose an asymptomatic condition requires a proof that a physician deviated from accepted medical practices in performing preparticipation screening of athletes and/or utilization of techniques that would have discovered the disease. American Heart Association came forward with the recommendations for cardiovascular preparticipation screening of athletes which represent the standard of care. But these standards will only be legally established as a standard of care if generally accepted and followed by physicians and relied upon by courts in determining the nature and the scope of legal responsibility in cases of sudden death. Preparticipation screening is the United States high schools and colleges largely take place at the discretion of the examining physician and customary practices. A considerably different approach powered by government legislation known as “Medical Protection of Athletic Activities Act” mandating preventive medical evaluations for all competitive athletes ages of 12-40 has existed in Italy since 1971. In Italy, all citizen engaging in competitive sports must obtain annual medical clearances from approved physicians stipulating that the athlete is free of cardiovascular abnormalities that would unacceptably increase the risk of sudden death. The evaluation in Italy consists of a history and physical examination, 12-lead ECG, exercise and pulmonary function tests and echocardiography (for soccer, boxing and cycling). The physician clearing the athlete to participate in a competitive sport bears responsibility for the diagnosis and becomes liable in an event of sudden death due to incorrect or incomplete diagnosis. Screening Practice in the United States Currently, the universally accepted standard of care in screening of high school and college athletes are not available in the United States. There are no approved certification procedures for medical professional that perform such screening examinations. A physician, a chiropractor, a nurse practitioner or a physician assistant can perform such examinations. The specification of what kind of specialist may perform such screenings is left upon each State. There are no formal agreements among the states on the format of the preparticipation medical evaluations. Many states require only standard history and physical examination forms for preparticipation screenings. Approximately 40% of the states either do not have recommended forms to serve as guides for the evaluation examination, or the forms used were judged inadequate against the recommendations of the American Heart Association (1, 2). What Can Present Screening Strategies Detect? Preparticipation screening consisting of history and physical examination alone without any noninvasive testing, such as an echocardiogram, does not possess sufficient power to guarantee detection of many critical abnormalities in large populations of trained athletes (5, 6). A significant congenital aortic valve stenosis is highly likely to be detected during a routine physical examination. However, hypertrophic cardiomyopathy (HCM), which accounts for the majority of sudden deaths in young athletes, may not be identified at all. The majority of athletes with HCM do not experience syncopal episodes, major arrhythmias or limitations of activity that would serve as clues to the evaluating specialist (1). The history and physical examination have the theoretic capability of at least raising suspicion of cardiovascular abnormalities that may trigger a sudden death. Genetic diseases, such as HCM, Marfan’s syndrome, arrhythmogenic right ventricular cardiomyopathy and premature coronary artery disease can be suspected based on the assessment of family history. The physical examination may identify components of Marfan’s syndrome, lesions that are associated with either aortic stenosis of partial obstruction to the outflow from the left side of the heart occurring at rest, the presence of systemic hypertension, to name a few. A recent retrospective study of 134 athletes who died suddenly from a variety of cardiovascular diseases showed that only 3% of those individuals exposed to standard preparticipation screening were suspected to have cardiac disease by virtue of those examinations, and less than 1% received a correct diagnosis (5). Overall, the preparticipation screening process as it is currently structured and carried out in the United States generally lacks sufficient power to consistently recognize clinically important cardiovascular abnormalities in many athletes. In contrast, in Italy routine ECG identified a number of athletes with HCM, with a similar prevalence of that in general population (7). Generally, the addition of noninvasive diagnostic tests to the screening process has the potential to enhance the detection of certain cardiovascular defects in young athletes. For example, an echocardiogram is the tool for clinical recognition of HCM, since the principal morphological component of this disease is the thickening of the left ventricular wall in the asymmetric fashion without a cause identified on physical examination. An echocardiogram is also expected to identify many other cardiovascular diseases responsible for sudden death in young athletes. In cases of diagnosis of anomalous coronary artery or arrhythmogenic right ventricular cardiomyopathy, a coronary angiogram or magnetic resonance imaging would be required. Issues of cost-efficiency paired with adequate staffing, training and financial resources are in many situations prohibitive to the use of echocardiography. For example, the cost of one comprehensive echocardiographic evaluation ranges from $400 to $2,000 with the average approximately around $600-$700, depending on the geographical cost of care. Assuming that HCM occurs in 1 out of 500 athletes, then the cost to diagnose one athlete with HCM would range from $250,000 to $400,000. In many cases, companies have donated equipment required to perform echocardiograms, and physicians have waived their professional fees for the evaluation of the examinations. However, such volunteer efforts cannot be relied on to deliver reduction of cost and providing care at the same time on a consistent basis across the United States. Training of physicians to appropriately regard borderline cases would be required if echocardiography is implemented for massive screenings. Some cases may as well demand further testing to establish a definitive diagnosis and rule out the risk of sudden death and that would involve additional health care costs, which may not be reimbursable under today’s managed care standards. In cases like that, an athlete would be exposed to a substantial amount of psychological stress combined with peer pressure, and financial and medical burden. It is also true that echocardiography may not identify all individuals at risk, when applied for massive screenings. The reasons for that have to do with late onset of the morphological components of the disease and technical factors related to imaging. The standard 12-lead ECG has been suggested as a more practical and cost-efficient alternative to population-based echocardiography. However, when used as a primary-screening test, the ECG suffers in comparison to the echocardiogram because it does not have the imaging capability. It is also possible to have HCM or another cardiac disease seen on echocardiography but have a normal ECG, and vice versa, it is possible to have an abnormal ECG and a normal echocardiogram. In cases like that, the adaptation of the heart to systematic training, known as "athlete’s heart disease" may play a role. HCM is an important cause of sudden death in young African-American athletes, and it is largely remains undiagnosed (7). Only 8% of all cases of HCM were identified in African-Americans, compared to 90% in Caucasians in a recent multi-hospital cohort study of 1,986 patients. This study parallels the finding of the study of 286 trained athletes that died suddenly from cardiovascular causes which reported 55% of HCM-related sudden death to had happen in African-Americans. It may be possible that HCM in African Americans represents a different, maybe a more malignant form of the disease. High index of suspicion is required when evaluating African-American athletes for participation in competitive sports. Even given this data, African-American athletes are less likely to be disqualified from competitive sports because of the risk of sudden death (2). It is clear that a series of definitive research studies are required to draw reliable conclusions to design the best system for screening of athletes. Notwithstanding the research studies is the acceptance of such guidelines by the athletic governing bodies and the legal system, which would require legislative efforts at the federal level. The National Registry of Sudden Death in Athletes is highly likely to provide important data for medical and legislative decision-making. References:
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For More Information: For more information on the causes of sudden death in athletes identified to date, click here. For more information on research and publications in medical journals on sudden death in athletes, click here. For information on sudden death in athletes appeared in the news, click here. For information regarding pre-participation screening of athletes and current initiatives, click here. |
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